Coronavirus disease 2019, also known as COVID-19, has rapidly become a worldwide emergency. The World Health Organization (WHO) has recently declared the global pandemic. The pathogen responsible for such infection is the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although the new COVID-19 virus is different from SARS-CoV, it uses the same host receptor, namely human angiotensin-converting enzyme 2 (ACE2).

Why dentistry is a risk branch?

The COVID-19 virus was recently identified in saliva of infected patients. Saliva can have a pivotal role in the human-to-human transmission. Dentists and other healthcare professionals that perform aerosol-generating procedures may be unknowingly providing direct care for infected but not yet diagnosed COVID-19 patients, or those considered to be suspected cases for surveillance. As in bronchoscopy, inhalation of airborne particles and aerosols produced during dental procedures on patients with COVID-19 can be a high-risk procedure in which dentists are directly and closely exposed to this virus. Therefore, it is crucial for dentists to refine preventive strategies to avoid the COVID-19 infection by focusing on patient placement, hand hygiene and all personal protective equipment (PPE).

Due to the characteristics of dental settings, the risk of cross infections may be high between dental practitioners and patients. For dental practices and hospitals all over the world (the outbreak is pandemic), strict and effective infection control protocols are urgently needed. Due to the unique characteristics of dental procedures where a large number of droplets and aerosols could be generated, the standard protective measures in daily clinical work are not effective enough to prevent the spread of COVID-19, especially when patients are in the incubation period, are unaware they are infected or choose to conceal their infection.

What can dentists do to protect themselves and patients?

Hand hygiene has been considered the most critical measure for reducing the risk of transmitting microorganism to patients (Larson et al. 2000). SARS-CoV-2 can persist on surfaces for a few hours or up to several days, depending on the type of surface, the temperature or the humidity of the environment (WHO 2020c). This reinforces the need for good hand hygiene and the importance of thorough disinfection of all surfaces within dental clinics. Every surface in the waiting room must be considered at risk; therefore, in addition to providing adequate periodic air exchange, all surfaces, chairs, magazines and doors that come into contact with healthcare professionals and patients must be considered “potentially infected”. It may be useful to make alcoholic disinfectants and masks available to patients in waiting rooms. The entire air conditioning system must be sanitized very frequently.

The use of personal protective equipment (including masks, gloves, gowns and goggles or face shields) is recommended to protect skin and mucosa from (potentially) infected blood or secretions. As respiratory droplets are the main route of SARS-CoV-2 transmission, particulate respirators (e.g., N-95 masks authenticated by the National Institute for Occupational Safety and Health or FFP2-standard masks set by the European Union) are recommended for the routine dental practice.

The management practice of the operating area should be quite similar to what happens with other patients affected by infectious and highly contagious diseases. As often as possible, the staff should work at an adequate distance from patients; furthermore, handpieces must be equipped with anti-reflux devices to avoid contaminations, improving the risk of cross-infections. Dentists should take strict personal protection measures and avoid or minimize operations that can produce droplets or aerosols. The 4-handed technique is beneficial for controlling infection. The use of saliva ejectors with low or high volume can reduce the production of droplets and aerosols (Kohn et al. 2003; Li et al. 2004; Samaranayake and Peiris 2004).

More useful recommendations for dental practice – as about evaluation of patients and oral examination or treatment of emergency cases – can be found in L. Meng1, F. Hua2 , and Z. Bian1 and also in Xian Peng1, Xin Xu1, Yuqing Li1, Lei Cheng1, Xuedong Zhou1 and Biao Ren (See References).

The need to stop and the need for clear guidelines

On 15 March 2020, the New York Times published an article entitled “The Workers Who Face the Greatest Coronavirus Risk”, where an impressive schematic figure described that dentists are the workers most exposed to the risk of being affected by COVID-19. As stated before, it is essential to give clear and easy guidelines to manage dental patients and to make working dentists safe from any risk. The transmission of the virus is mainly through inhalation/ingestion/direct mucous contact with saliva droplets; it is also critical to remember that the virus can survive on hands, objects or surfaces that were exposed to infected saliva.

Figure is taken from the NYT article: The Workers Who Face the Greatest Coronavirus Risk

Although in some countries dental offices have been closed during the epidemic, a large number of emergency patients still go to dental clinics and hospitals for treatment. In any case, the most recommended guidelines indicate that dentists should avoid scheduling any patient: only such urgent dental diseases should be considered for intervention during the COVID-19 outbreak. This action will drastically limit interpersonal contacts, waiting time of patients in dental cabinets and, in general, conditions predisposing patients to be infected.

Recently, the European organisations of Health Professionals published a statement on COVID-19. In that document, they urged the European Commission and governments to support and protect healthcare professionals fighting SARS-CoV-2.

Prediction models

Several prediction models for Covid-19 have been recently published to support decision-making processes. Nonetheless, data are still scant, at high risk of bias and probably optimistic. More rigorous prediction models are needed and should be verified. (in Wynants, Van Calster…)

Specific protocols for weak patients, just like older adults (in Montero-Odasso, Goens, Kamkar…) and young pediatric patients (in Mallineni, Innes, Raggio…), should be urgently developed and shared to increase the efforts of the international dental community to manage properly the Covid-19 crisis.

Decision making processes in patient management

In order to perform a clinically- and ethically-driven decision-making process, dental interventions can be divided in the following categories:

Emergency management of life-threatening conditions;

Urgent conditions that can be managed with minimally invasive procedures and without aerosol generation;

Urgent conditions that need to be managed with invasive and/or aerosol-generating procedures;

Non-urgent procedures;

Elective procedures.

Furthermore, the following considerations should be assessed before starting any urgent treatment.

Operative procedures should be as minimally invasive as possible and aerosol-generating interventions should be avoided whenever possible;

Disposable devices and instrumentation should be used whenever possible to limit cross-infection risks;

Conclusions (21 April 2020)

The treatment of COVID-19 is fundamentally based on containment measures: in China and South Korea, the severe application of such interventions has regularly and drastically reduced new cases and this experience shows that a reversion of epidemic growth is possible in the short-term. Many countries are investigating to get a possible vaccine as soon as possible. In the meantime, doctors are testing promising medicines to relieve symptoms and countries are all trying to avoid health systems crisis.

Financial Problems

The pandemic resulted in serious financial problems faced by dental offices, hospitals and healthcare operators. Dental interventions are currently limited to urgencies and the management of patients has become expensive and unpredictable. Healthcare workers are facing serious financial challenges and the intervention of competent authorities is claimed as very urgent to provide support and help to dental offices, hospitals and healthcare operators. (Farooq, Ali)

So, it is doubtful that the significant limitation of clinical and surgical activities in the medical and dental sector has represented a very impactful measure on the economy of the sector.

Impact of the interventions

Nevertheless, this drastic intervention can make it possible to protect the health and safety of citizens and contain the expansion of the COVID-19.

Citizens do their part. For example, speaking of children’s oral health, parents should be helping children develop good oral and diet habit such as effective brushing and flossing to avoid oral diseases and emergency.

On its webpage, the American Dental Association (ADA) has also published a link to frequently asked questions useful to dental professionals, mainly regarding personal protective equipment and patient communications. See references and online resources below for more info.

DISCLAIMER: This is fundamentally a summary of the most important concepts taken from the articles published on PubMed about Dentistry and the new coronavirus, The purpose is educational. We, as a point of reference for the dentists on the web, want to help everyone to get clear, trustful, information.

Graduated in Linguistics and Specialised Translation at the University "l'Orientale" of Naples. Works as a digital marketing specialist.Soon started focusing on Dentistry. Joined pioneering web-side projects as Zerodonto and the Studio Dentistico Cozzolino in 2014 and keep working on them.In 2016 worked as a copywriter and digital strategist for WASITA, an Italian Web Agency.Some few other projects, especially on advertising management. In the portfolio: Capri Watch, Festival dell Filosofia in Magna Grecia.From 2019 on, he is the sole administrator of Zerodonto SRL and Dentalnecto SRL.His blog is asocialman.com

Graduated with full marks and honors in Dentistry in 2002 at the University Federico II of Naples. Post-graduate course in “Traditional and implant-supported prosthodontics and restorative biomechanics” (2003); Master of Science and PhD in “Dental materials and their clinical applications” at the University of Siena (2004-2006); post-graduate course in “Smile esthetics” (2012).
Research Professor of Prosthodontics and Digital Dentistry at the University Federico II of Naples.
Qualified as Full and Associate Professor in 2017. Aggregate Professor of Prosthodontics and Digital Dentistry at the University Federico II of Naples and at the University of Siena.
Lecturer at several national and international Post-graduate and Master Courses in different Universities.
Researcher, expert and consultant for national and international dental companies.
Coworker in several PRIN projects and Principal Investigator of a FIRB research project about “Biomechanics and biomimetics in implant-supported prosthodontics” shared between the Second University of Naples and the University “Vita Salute San Raffaele” of Milan.
Author of more than 130 publications in national and international peer-reviewed scientific journals and co-author of chapters of books on Prosthodontics. Reviewer of more than 30 international peer-reviewed scientific journals. Speaker at national and international meetings.
Past President of the Membership and Recruitment Committee of the International Association for Dental Research (IADR). Member of the Academy of Dental Materials (ADM) and of the Italian Society of Dentistry and Maxillo-Facial Surgery (SIOCMF). Past Secretary of the Italian Society of Prosthetic Dentistry and Implant Prosthodontics (SIOPI).
Winner of many national and international prizes for research and clinical activity in prosthodontics, esthetic dentistry, biomechanics and dental materials.
Co-founder of the dental blog and community Zerodonto (www.zerodonto.com).Complete resume here.

Graduated with full marks and honors in Dentistry at the University ‘Federico II’ of Naples in 1996. Attended a post-graduate course in Periodontology and Implant Dentistry at the Dental School of the University ‘Federico II’ of Naples in 1999-2000. In 2003, received the PhD in Periodontology at the same University.
Co-Author of the textbook ‘Atlas of Bracketless fixed Lingual Orthodontics’, Quintessence Publishing.
Lecturer at several national and international congresses. Post-graduate and Master Courses.
Works as a private practitioner in Naples, Italy.
Founder of Zerodonto, dental blog and online community.
His main clinical interests are Periodontics and Implant Dentistry.Complete resume here.

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